The optimal screening strategy for chronic hepatitis B virus infection in China – Authors' reply
Authors: Shu Su, William CW Wong, Jason J Ong, Wai-Kay Seto, Lei Zhang
Journal: The Lancet Global Health (2022)

We thank Min Liu and Jue Liu for taking the time to read our study and respond to our published manuscript.1Su S Wong WC Zou Z et al.Cost-effectiveness of universal screening for chronic hepatitis B virus infection in China: an economic evaluation.Lancet Glob Health. 2022; 10: e278-e287Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar They suggest that hepatitis B virus (HBV) screening for key groups and groups at high risk might be a better strategy for China to achieve the 2030 HBV elimination target than by universal screening. Although targeted screening has its advantages in reducing the initial monetary investment and can be implemented in resource-scarce settings, identifying the key groups and groups at high risk themselves could be a major barrier for its implementation. A previous study showed that it was challenging to identify populations at high risk of HBV—eg, those who had a history of unsafe blood transfusion, intravenous drug use, or high-risk sexual behaviour, and those who were not vaccinated on time.2Wang F-S Fan JG Zhang Z Gao B Wang HY The global burden of liver disease: the major impact of China.Hepatology. 2014; 60: 2099-2108Crossref PubMed Scopus (798) Google Scholar Furthermore, the identification process might lead to the additional risk of associating the high-risk behaviours with HBV infection, resulting in double stigmatisation of the disease. We believe that universal HBV screening provides a practical option to identify undiagnosed people with chronic hepatitis B infection. As of 2016, only around 19% of people with chronic HBV had been diagnosed, and most were among the general population with no obvious identification with key groups or groups at high risk. Timely diagnosis for these patients can enable earlier initiation of treatment and better management of chronic hepatitis. Mass screening for COVID-19 has been used to control the spread of the pandemic for an entire city (eg, Wuhan) in a short time frame in China3Shen M Xiao Y Zhuang G Li Y Zhang L Mass testing—an underexplored strategy for COVID-19 control.Innovation (N Y). 2021; 2100114 Google Scholar and arguably, population-based cervical cancer screening has been implemented nationally and internationally with good population impacts and cost-effectiveness.4Zou Z Fairley CK Ong JJ et al.Domestic HPV vaccine price and economic returns for cervical cancer prevention in China: a cost-effectiveness analysis.Lancet Glob Health. 2020; 8: e1335-e1344Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar We excluded children aged 0–17 years because they were born after 2002 when the state-funded HBV vaccination programmes started. In this age cohort, it is estimated that their HBV vaccination coverage rate is 95% and the vaccine protection rate is 98–100%. The incidence of HBV diagnoses among children is as low as 3·51 per 100 000 and China has achieved the WHO target of reducing incidence cases by 90% in that age group.5National Population and Health Science Data Sharing PlatformThe Data-center of China Public Health Science. Hepatitis.https://www.phsciencedata.cn/Share/en/data.jsp?id=9906073c-200a-4b44-8ffe-0867bfa42557&show=0Date: 2022Date accessed: February 28, 2022Google Scholar Thus, this cohort of children has a very low infection risk and would not require universal screening for hepatitis B virus. We agree that given China is a populous country, linkage to care after HBV diagnosis would be essential to prevent further transmission and disease progression. Therefore, we are further exploring the optimal treatment strategies on HBV management to examine how to reduce the costs of medication, health-care, and personnel should a large number of infections be identified. The combined approach of screening and linkage to care, together with a comprehensive treatment and surveillance strategy, will be essential to China's achieving eventual HBV elimination and removing HBV as a public health threat. We declare no competing interests. Cost-effectiveness of universal screening for chronic hepatitis B virus infection in China: an economic evaluationThe five-test universal screening strategy in people aged 18–70 years, implemented within the next 10 years, is the optimal HBV screening strategy for China. Other screening strategies could be cost-effective alternatives, if budget is limited in rural areas. Delaying strategy implementation reduces overall cost-effectiveness. Early screening initiation will aid global efforts in achieving viral hepatitis elimination. Full-Text PDF Open AccessThe optimal screening strategy for chronic hepatitis B virus infection in ChinaShu Su and colleagues (February, 2022),1 in their Article on the cost-effectiveness of universal screening for chronic hepatitis B virus (HBV) infection in China, found that the five-test universal screening strategy in people aged 18–70 years, implemented within the next 10 years, is the optimal HBV screening strategy for China. Full-Text PDF Open Access